Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis

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1 Predictors of Physical Therapy Use in Patients with Rheumatoid Arthritis Maura Iversen,, PT, DPT, SD, MPH 1,2,3 Ritu Chhabriya,, MSPT 4 Nancy Shadick, MD 2,3 1 Department of Physical Therapy, Northeastern University, 2 Section of Clinical Sciences, Division of Rheumatology, Immunology & Allergy, Brigham & Women s s Hospital, 3 Harvard Medical School, 4 Sunnyvale Physical Therapy and Hand Rehabilitation, Sunnyvale, CA 1

2 Evidence Based Medicine Li L, Bombardier C. Utilization of physiotherapy and occupational therapy by Ontario rheumatologists in managing rheumatoid arthritis: a survey. Physiother Can 2003 Winter; 55(1): Kennedy N. Keogan F. Fitzpatrick M. Cussen G. Wallace L. L Characteristics of patients with rheumatoid arthritis presenting for physiotherapy management: a multicentre study. Musculoskeletal Care 2007; 5(1):20-5. Martin LJ. Griffith SM. High disease activity scores predict the need for additional health services in patients over 60 with rheumatoid arthritis. Musculoskelt.. Care. 2006;4(1):1-11. Iversen MD et al How Rheumatologists and Patients With Rheumatoid Arthritis Discuss Exercise and the Influence of Discussions on Exercise Prescriptions Arthritis & Rheumatism (Arthritis Care & Research) 2004;51(1);

3 Impact of Rheumatoid Arthritis The estimated annual cost of RA in United States is over 8.7 billion dollars (Ramsburg KL 2000) Patients with RA are 8x more likely to have functional disability as compared to adults in general populations of same community. (Sokka,, T et al. 2003) 30% patients with RA have permanent work disability within first 3 yrs of diagnosis (Sokka,, T. 2003) 3

4 Physical Therapy (PT) and RA PT is recommended by the ACR, EULAR and professional societies to manage symptoms of RA Use of PT services leads to significant improvements in self-efficacy, pain & disease activity (p<0.01) (Lineker 2001) PT plays an integral role in helping patients cope with chronic pain and disability (Matsuta, K; T. 1992; Lineker 2001; Newsome 2002), K; Kikuna, Increased ability to perform ADLs 2002)thereby, reducing disability ADLs (Newsome 4

5 Use of Physical Therapy in Rheumatoid Arthritis Although physical therapy (PT) is proven to be effective, it is underutilized In Ontario 26.5% of rheumatologists refer patients to PT (Li et al 2003) Cross sectional study of outpatients, 22.5% of RA patients had unmet demands for PT (Martin 2006) A US study reported rheumatologists referred only 26.5% patients to PT (Iversen et al. 2005) In Germany, 44% of RA patients received individual PT (Zink et al. 2001) 5

6 Purpose and Design Purpose: To identify factors associated with use of Physical Therapy services among patients with Rheumatoid Arthritis Design: Design: Secondary analysis of a large prospective cohort 6

7 Subjects 1032 patients enrolled in the BRASS Registry at Brigham and Women s Hospital (BWH) Inclusion criteria: Patients aged >= 18 years and diagnosed with RA or sero- negative inflammatory arthritis (ICD-9 codes) Meets American College of Rheumatology criteria for RA Completed 12 month follow up survey Exclusion criteria: Patients diagnosed as Psoriasis or SLE Patients <18 yrs 7

8 Measures Variables Demographic features Medical history Self-efficacy Disability Disease activity Social networks Fatigue Physical activity Measures Age, gender, education, income, race, insurance, employment, marital/living arrangement status Number of Co-morbidities, RA medications, duration of RA symptoms Arthritis self efficacy scale (Lorig et al.1998) MDHAQ (Pincus et al. 1999) RADAI (Stucki et al 1995) Berkman Syme Social Network Index (Berkman S. 1979) MDHAQ Fatigue (Pincus et al. 1999) Previous h/o exercise 8

9 Analyses Outcome: Use of Physical Therapy (y/n( y/n) Descriptive statistics to characterize sample T-tests, Chi Squared, Wilcoxon Rank Sum tests to examine differences between those who completed and those who dropped out Univariate comparison of independent variables with outcome Variables grouped and entered into logistic regression model to determine most significant predictor in group Final multivariate logistic regression 9

10 Recruitment Results 10

11 Features of Patients Who Completed the Follow-up and Those Who Did Not (n=1032) Baseline Variables Completed f/u (n=772) Did Not Complete (n=260) Mean Age (yrs) 56.3 (±13.6) 56.2 (±15.5)( NS Female 642 (83.2%) 208 (80%) NS College Graduates 171 (22.2%) 63 (24.9%) NS Income ($70k-$90k) 330 (50.3%) 89 (45.3%) NS Caucasian 719 (93.6%) 251 (96.8%) NS Married 498 (64.7%) 164 (63.1%) NS Disability 71 (9.8%) 25 (10.7%) NS Co-morbidities 1.8 (± 1.30) 1.6 (± 1.26) NS RA diagnosis < 2 yrs 155 (20.1) 63 (24.2) NS Previous h/o exercise 209 (27.1%) 65 (25%) NS P-value 11

12 Health and Psychosocial Status Of Those Who Completed and Those Who Did Not (n=1032) Baseline variables Completed (N=772) Did Not Complete (N=260) P-value Median MDHAQ (range) 0.63 (0-3) 0.6 (0-3) NS Median Self efficacy (range) 75 (10-100) 70 (10-100) NS Disease Activity (RADAI) : Mild (<=3.1) Moderate (3.1 to <=5.1) Highly active 354 (45.8%) 184 (23.8%) 234 (30.3%) 105 (40.4%) 55 (21.2%) 100 (38.4%) Mean Fatigue (SD) (± 28.78) 42.5 (± 29.1) NS Social network scale Level I Level II Level III Level IV 100 (14.9%) 286(42.6%) 148 (22.0%) 138 (20.5%) 44 (17%) 104 (40%) 65 (25%) 47 (18%) NS NS 12

13 Number of PT Visits per Subject 4.3% 3% 2.5% 13

14 Variables Grouped Based on International Classification of Function (ICF) Health Condition Rheumatoid Arthritis Body Structures and Functions RADAI, number of comorbidities, fatigue, duration of illness Activity Limitation MDHAQ Participation Restriction Environmental Income, employment Contextual status, factors insurance, social networks, medications Personal Contextual Age, gender, factors race, education, self efficacy, disability, prior use of exercise, marital status 14

15 Univariate Relationships with Primary Outcome- PT Use (Y/N) Odds Ratio (95%CI) Age (< 60 yrs vs 60+) 1.0 ( ) Female 1.2 ( ) Education 2.2 ( ) On DMARDs, biologics, steroids 1.9 ( ) Unemployed on Disability 2.4 ( ) Health Insurance 0.4 ( ) Married or Living with Partner 0.8 ( ) Caucasian 0.9 ( ) Exerciser 1.8 ( ) Income (< 70 k versus >= 70 K) 0.5 ( ) 15

16 Bivariate Relationships with Primary Outcome- Use of PT Odds Ratio (95% CI) Disease Activity 1.2 ( ) Disease Duration ( >= 2 yrs vs < 2 yrs) 1.4 ( ) Fatigue 1.2 ( ) Disability (MDHAQ >= 1 vs < 1) 1.7 ( ) Arthritis self-efficacy 1.2 ( ) Co-morbidities 1.1 ( ) Social Networks (Berkman Syme Index) 1.07 ( ) 16

17 Predictors of Physical Therapy Use in Persons with RA (n=671) Predictors Body Structures and Function Odds Ratio 95% CI Disease Activity (RADAI) Contextual factors Unemployed on Disability Education Social Networks (BSNI) C= 0.68 (Model statistic) 17

18 Discussion Our patients were primarily Caucasian females who had a high income, were well educated and had strong social networks 15.3% of the sample received PT services slightly lower than the prior reports (Li et al 2003, Martin J 2006, Zink et al. 2001, Iversen et al 2005) ICF framework was useful in identifying contextual factors associated with PT use. (Cieza A, Stucki G 2005) 18

19 Discussion: Disease activity and Use of PT Services 19

20 Discussion Greater social networks associated with: lower mortality (Berkman Berkman,, 1979; Giles,2009) provide access to care (Berkman,, 1979) motivation and information/advice about health services (Lubben et al 1988) Patients with higher education, even among well educated persons, were 50% more likely to use PT services Income was not significant after adjusting for social support and education

21 Discussion While fatigue has been identified as a predictor of PT service use (Waltz,2000), disease activity was a stronger predictor Physical disability has been shown to predict referrals for PT (Waltz M 2000) Disability, as measured by HAQ, was found to be significant predictor for utilization of PT services (Jacobi et al 2001) but was not significant in the multivariable model 21

22 Limitations Our sample was not culturally and SES diverse, so the results of this study cannot be generalized to all patients with RA While the study captured information on many known attributes associated with PT service use, it did not capture all potential attributes. 22

23 Strengths Used a combination of demographic, health, psychological and clinical factors to identify predictors of PT service use Large sample Used theoretical framework (ICF) for model building Limited missing data 23

24 Conclusion Patients with greater disease activity and disability and who are well educated with strong social networks were more likely to receive PT services. This study helps to identify new contextual factors associated with PT service use 24

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